Mathauer, I., Saksena, P. & Kutzin, J. Pooling arrangements in health financing systems: a proposed classification. The purpose of pooling is to spread financial risk across the population so that no individual carries the full burden of paying for health care. This classification can help countries to assess their pooling setup and understand the particular nature of fragmentation issues on the basis of which to identify feasible pooling options as well as other possible mitigating measures to address fragmentation. 0000008860 00000 n Alternatively, in a non-competitive arrangement, people could be assigned to specific pools, with enrollment being based on explicit criteria, so that the different pools cannot compete for beneficiaries [11]. there is no explicit purchaser-provider split. While independent attributes, these often go together, as larger pools are more likely to include a greater diversity of risks. Many of those with non-contributory entitlement are paying taxes in some form, but the distinction is the absence of direct linkage between explicit contribution and entitlement. volume18, Articlenumber:198 (2019) 0000014993 00000 n Q J Econ. Likewise, when their sizes differ across the country, they could turn out to have unequal redistributive capacities [14]. 2012;380(9849):125979. Gottret P, Schieber G. A practitioners guide health financing revisited. Lancet. Akerlof GA. Spending targets for health: no magic number. 14]: The World Bank; 2013 [http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/MexicanSocialProtectionSysteminHealth.pdf. 0000080000 00000 n 2019, 5/393(10166):75102. Int J Equity Health 18, 198 (2019). But a system with territorially distinct pools can suffer from fragmentation, if and when their population size or the territory are too small to ensure redistributive capacity, or when sub-national territories have very different levels of average per capita expenditure on health. We also like to thank Lisa Seidelmann, Carlo Schmid Fellow and volunteer with the Department of Health Systems Governance and Financing at the time of producing this draft for her research assistance. However, there are some examples from larger or very large countries, such as Hungary [35] and Turkey [36]. Fragmentation also occurs in the few countries (Germany, Netherlands, Chile) that allow certain population groups (e.g., the self-employed or individuals above an income threshold) to opt out from the public system and to buy mandatory private insurance [59,60,61]. Health financing for universal coverage and health system performance: concepts and implications for policy. This article provides an overview of health financing reforms across countries in the Western Pacific Region as progress is made toward universal health coverage (UHC). Decentralized countries often have pools organized by government administrative levels. Risk pooling effectively means that the healthy subsidize the sick, and by implication due to their lower health risks, the young subsidize the old [14]. sicker individuals would have to pay more because they would need more health services [18]. It serves multiple purposes, e.g. Management has five main functions: planning, organising, leading, coordinating and control. Geneva: World Health Organization; 2010. !{~4nf0QMh92]Ta, *eIF population density). 0000010947 00000 n The complex structure of Australia's . These latter three were replaced by a new health coverage scheme that was introduced in 2002, called the Universal Coverage Scheme (UCS), as a response to growing concerns about the huge differences in level of funding per capita across the schemes and the remaining coverage gap due to the failure of the voluntary insurance to reach much of the informal sector. This is followed by an outlineof the key institutional design aspects of pooling arrangements and how these can create fragmentation. Geneva: World Health Organization; 2017. However, evidence for efficiency improvement with increased market competition among purchasers is weak [25]. . Promoting strategic purchasing Making the purchasing of health services more strategic is critical for countries to progress towards universal health coverage. Cuba, with a much larger population, also has this setup, as does Sri Lanka, where financial protection performance is relatively good despite a high share of OOP [29]. A 2 0 The threebasicfunctions ofanyhealthfinancingsystemare revenuecol lection,riskpooling,andpurchasingofservices.Figure3.1highlightsthese basic functions, together with the basic health system objectives they are designedtoachieve.Countriesneedtofocusnotongenericmodelsbuton healthfinancingfunctions andobjectives andthespecificmicroandmacro type of pooling arrangement, namely territorially distinct pools. On the one hand, some have argued that a multiple competitive fund setup has the advantage of offering choice to beneficiaries and may create incentives for innovations, especially for purchasing. For example, even in a single or unified pool, unless health needs are perfectly reflected in the relative allocations to different health programs, further fragmentation occurs, especially when an input-based line item budget structure is in place. Bonilla-Chacn ME, Aguilera N. The Mexican Social Protection System in Health [Universal Health Coverage Studies Series (UNICO) No. Today, millions of people do not access services due to the cost. hbbd``b` "$8@B\HHo \Q u 88b``g T Preker A, Langenbrunner J. Bethesda: Health Finance & Governance Project, Abt Associates Inc; 2018. Promote sustainability of health financing project activities with effective networking, linkages to other programs, and capacity building of NIPs on health financing activities. In Switzerland, this insurance system is further territorially divided up, in that the multiple pools operate within each sub-national unit [50]. the mobilization of resources for the health sector; 2) pooling, i.e. As a Msc in Public health student l compiled some videos on Public health that l found useful during my course. Taken quite literally, perhaps no country has only one single pool. On the other hand, competition among insurance pools creates an incentive for pool managers to cream skim, i.e. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 1.2.1. [http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/swaziland/swaziland_nhssp_ii_draft_zero_29_aug_2014.pdf. Health financing has three key functions: revenue collection, pooling of resources, and purchasing of services. 2016;18(2):1239. Business Finance refers to corporate finance in the business world which is responsible for allocating resources, creating economic forecasts, evaluating equity and debt opportunities and many more functions within an organization. To develop the classification, we combined the different features in the structure and the nature of pooling and then examined the nature and structure of pooling in more than 100 countries across all income groups. At the sub-national and health facility levels, programs strengthen the capacity for budgeting and financial management to increase accountability, reduce waste, and ensure that provider incentives are aligned with improved health outcomes. A conclusion and lessons are presentedat the end. Various policy instruments and options exist to reduce fragmentation and increase redistributive capacity: 1) make participation compulsory to cover everybody; 2) merge different pools to increase the pool size and diversity in health risks; 3) cross-subsidize pools that have lower revenues and higher health risks; and 4) harmonize across pools, such as benefits, payment methods and rates [16]. In the health sector, Malaysia was to gradually move away from a policy of highly subsidized care for all population groups, encouraging the growth of the private sector in health and shifting to other financing methods, including insurance, to finance the healthcare system (Khoon, 2010). There is certainly a tradeoff between coming to a useful, parsimonious number of categories and losing important nuances. Kutzin J. This paper proposed an initial classification of eight broad types of pooling arrangements, how fragmentation manifests and its consequences in each. Geneva: World Health Organization; 2016. Risk adjustment and risk selection in Europe: 6 years later. However, as with any classification, it is a simplification of reality, and the aim is not merely to categorize a country in one type or another. Objective Health financing assessment is of growing interest to policy makers to develop reform strategies towards achieving universal health coverage. Over time, the result is that benefits are curtailed for those who need them most, while fewer and fewer healthier individuals join the scheme. The main difference to the previous pooling arrangement is that there exist explicit coverage schemes for the poor and sometimes for the entire population outside of the formal sector. Taskforce on Innovative International Financing for Health Systems. It is also a major public policy concern because of the spillover effects for the wider system, since the well-resourced private insurance system distorts the distribution of scarce health workers and other inputs to the service of the voluntarily insured at the expense of the rest of the population [41]. View below: When viewing on a desktop, maximize for optimized view. The UCS pooled together all of those revenues plus increased budget allocations. the allocation of pooled funds to health service providers [1]. Cashin C, Nakhimovsky S, Laird K, Strizrep T, Cico A, Radakrishnan S, Lauer A, Connor C, ODougherty S, White J, Hammer K. Strategic health purchasing Progress: a framework for policymakers and practitioners. As such, pooling is also a distinct policy instrument, because a health systems pooling arrangement greatly influences the extent to which progress can be achieved independent of the overall level of prepaid funding available. Beyond survival protecting households from health shocks in Latin America. When people have access to publicly financed coverage schemes, this VHI is duplicating. 0000002300 00000 n Prakongsai P, Limwattananon S, Tangcharoensathien V. The equity impact of the universal coverage policy: lessons from Thailand. Cite this article. general tax revenues or a combination of those revenues and social insurance contributions from employers and employees [30]. SMG 1117A.641 . As such, automatic entitlement is typically solely funded from general budget revenues. 0000013724 00000 n Health financing systems have a key role in achieving universal health coverage (UHC) across the globe. 814 0 obj <>stream As such, this type of pooling arrangement, if and when it has an effective risk adjustment mechanism that deters risk selection efforts, can act as a virtual single pool (due to the flows between the pools). Strategic purchasing for universal health coverage: key policy issues and questions. Health Financing Indicators Reference Sheets, compendium of indicators for projects supporting health financing, human resources, and governance, Health Financing Indicators Reference Sheet 2014, Health Finance and Governance (HFG) Project. Washington DC: World Bank; 2006. This was, and in some places remains, one of the main drivers of large inefficiencies in the health systems of the ex-USSR countries [15]. 2016;15:57. Cookies policy. Health financing for UHC consists of three core functions: 1) revenue raising, i.e. Some countries, such as Rwanda and Ghana, have transformed their earlier CBHI model, which no longer falls under VHI. 2019;97:33548. To explore the impact of foreign aid on low- and middle-income health systems. Gautier J. Health financing involves the basic functions of revenue collection, pooling of resources, and purchase of interventions. Mathauer I, Dkhimi F. Analytical guide to assess a mixed provider payment system. However, mandatory coverage is often not implemented because it is difficult to enforce, especially with respect to people working in the informal economy. Thailand is a prominent example for this pooling arrangement. A multiple pool setup can be based on population segmentation, i.e. PLoS ONE. Voluntary health insurance (VHI) with a primary coverage role is usually offered by multiple insurers competing for clients. endstream endobj 168 0 obj<>stream Instead, they usually follow a countrys territorial structure, i.e. Kutzin J, Shishkin S, Bryndov L, Schneider P, Hrobo. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. The Health Financing Specialist will support CA-CSU and MSP to engage key government and private sector stakeholders to strengthen health financing for health. However, little is known about how best to monitor health financing system progress towards UHC, especially in low- and middle-income countries. These attributes are [1] large size in terms of the number of people covered by the pool, and [2] diversity of health risks within the pool [1]. Terms and Conditions, 0000014440 00000 n 2007;83(23):16279. Compulsory participation refers to the legal requirement that someone be included for coverage and goes hand-in-hand with contributory-based entitlement, i.e. Pooling revenues and reducing fragmentation Pooling revenues and reducing fragmentation Pooling is a core function of health financing policy. . Health financing policy is key to the health system, as it determines: i) the sources of fund, and therefore how much is available to the sector; ii) how health risks are pooled; iii) who controls the funds and how they are allocated; iv) The equity of the sector funding, and hence indirectly, how many people will fall into poverty (or not) as a Kutzin J, Yip W, Cashin C. Alternative financing strategies for universal health coverage. The administrative costs are even greater where there are actually different service providers associated to each financing arrangement. Key facts I'.1~)4CQ~u sd1$V0c: B' {09 At one extreme is a single pool of all funds for health services covering the entire population of a country. the allocation of pooled funds to health service Cutler DM, Zeckhauser RJ. There are different classifications for finance functions, and it varies with organization types. In: Figueras J, editor. Health Systems Financing: The path to universal coverage. Mathauer I, Vinyals Torres L, Kutzin J, Jakab M, Hanson K. Pooling financial resources for universal health coverage: options for reform, Bulletin World Health Organization (forthcoming). While the issue of segmentation first emerged in Latin America [43], it is not limited to that region. The extent to which a health financing system effectively attains this risk pooling objective is affected by the amount of revenues raised, how well health services are purchased, and also by the design of pooling arrangements. Jowett M, Brunal MP, Flores G, Cylus J. European Observatory on Health Systems and Policies; 2014. In turn, this may result in a cycle of increasing premium rates and other actions that insurers take to reduce their risks and improve their financial sustainability. IM is a senior health financing specialist; JK is the coordinator of the Health Financing Team, they both work in the Department of Health Systems Governance and Financing at the World Health Organization in Geneva. 0 Geneva: World Health Organization; 2017. 2016;15(1):165. Agustina R, Dartanto T, Sitompul R, Susiloretni KA, Suparmi AEL, Taher A, Wirawan F, Sungkar S, Sudarmono P, Shankar AH, Thabrany H. Universal health coverage in Indonesia: concept, progress, and challenges. Which approach is used will have a big impact on equity, on efficiency, on incentives, and on the supply of health care. Mathauer I, Kutzin J. the accumulation and management of prepaid financial resources on behalf of some or all of the population; and 3) purchasing, i.e. Moreover, in France, there is a shift towards compulsory complementary coverage, which employers have to buy for their employees since 2016 (with exceptions for various employee groups) [56]. comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. Pooling arrangements influence not only risk pooling (and via this pathway, financial protection and equity in service use), but also the intermediate UHC objectives of efficiency and equity in the distribution of a health systems resources. Even in countries with highly centralized pooling, there are usually several pools of funds that are used to pay for some health services, for example occupational health programs, supply-side funding for other government services such as those delivered through vertical programs or voluntary health insurance [1]. Jowett M, Kutzin J. For example, in France and Slovenia, 90 and 84% respectively of the population have complementary VHI coverage, and premiums for complementary VHI are subsidized for low-income households. Health financing is central to the functioning of health systems and the attainment of health-related sustainable development goals, including universal health coverage (UHC). Territorially distinct pools have much in common with a single national pool. Adverse Selection in Health Insurance. PubMed 787 0 obj <> endobj Then, within each health financing function, key performance issues and associated measurable indicators are developed. xref 2023 BioMed Central Ltd unless otherwise stated. a single pool; (2.) VHI with a complementary or supplementary role exists in most countries [53, 54]. Financial Management Functions. 0000012340 00000 n Programs build local capacity to track public and private health spending. The level of per capita funding of the UCS has converged with that for the private sector employees scheme, but the civil servants still benefit from much higher levels of spending [45, 46]. World Health Organization. In a well-functioning healthcare system, the financing of healthcare is defined by three key functions: (1) revenue generation, which involves the mobilization and collection of funds from different sources; (2) resource pooling, where generated revenue is accumulated to ensure availability to the population in need; and (3) the purchasing In healthcare management there are three managerial levels: top-level, middle-level and frontline managers. The classification is presented in Fig. endstream endobj 788 0 obj <>/Metadata 86 0 R/OCProperties<>/OCGs[800 0 R]>>/Outlines 125 0 R/PageLayout/SinglePage/Pages 783 0 R/StructTreeRoot 156 0 R/Type/Catalog>> endobj 789 0 obj <>/ExtGState<>/Font<>/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 790 0 obj <>stream World Health Report. Annual report 20152016. World Health Organization. 3. They also need to monitor cash on hand, businesses may be profitable but have a shortage of cash and. The Second National Health Sector Strategy Plan 20142018: Towards attainment of Universal Health Coverage, Draft Zero 29 August 2014. The function of pooling and the ways that countries organize this is critical for countries progress towards universal health coverage, but its potential as a policy instrument has not received much attention. To discuss Malawi as a case study in health systems. Mutuelle sant d'entreprise : les obligations de l'employeur ; 2018, https://www.service-public.fr/professionnels-entreprises/vosdroits/F33754 (Accessed on 10 January 2018). Health care delivery forms the most visible function of the health system, both to patients and the general public. This mitigates some of the effects of segmentation, though remains often incomplete due to the entrenched power of the initially insured population groups. Innovations in health system finance in developing and transitional economies. OECD, Eurostat. Discussion paper. FDA Staff Manual Guides, Volume I - Organizations and Functions . trailer Fragmentation in pooling is a particular challenge for UHC objectives. ), (7.) WHO. All people have in principle access to the same benefits. Such systems are primarily found in both large and smaller higher-income countries like Germany, Netherlands, Switzerland, Czech Republic and Slovakia [15, 26]. Baeza CC, Packard TG. Self-paced (approximately 6 hours of course time) Click to enter this course The operation of a health financing system entails transactions by the three main functions of health financing: revenue-raising, pooling and purchasing - such as, for example, payment of social insurance contributions to a single national fund and distribution of the resources, first among the different purchasing organisations, and then . Peru has also made considerable progress with its Integrated Health System (SIS), a budget-funded explicit coverage scheme for the poor, and increasingly more of the informal sector [49]. These are 1) the nature of pooling and 2) the structure of pooling. Pools may be organized as territorially distinct. to (5.) Therefore, resource allocations from the central to sub-national levels need to be risk-adjusted to account for differences in population size, the health risk profiles of people as well as for other factors that may affect the relative health needs (e.g. Such an unequal distribution of resources is frequently found, in that available system resources are strongly skewed to those using VHI as their primary coverage. The finance department functions like bookkeeping, budgeting, forecasting, and management of taxes, and the finance manager functions like financial report preparations contribute to the overall financial wellbeing of an entity. BMC Health Serv Res. 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Countrys territorial structure, i.e concepts and implications for policy a greater diversity of risks purchasing!, 198 ( 2019 ) out to have unequal redistributive capacities [ 14 ] health service DM... On 10 January 2018 ) are more likely to include a greater of... Exists in most countries [ 53, 54 ] country has only one pool! Useful, parsimonious number of categories and losing important nuances examples from larger or very large countries, as... Even greater where there are different classifications for finance functions, and of!, parsimonious number of categories and losing important nuances Plan 20142018: towards attainment of universal coverage! Coverage: key policy issues and questions hand-in-hand with contributory-based entitlement, i.e on hand, among. Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations health shocks in Latin America 43! Zero 29 August 2014 a countrys territorial structure, i.e and transitional economies ;. Shishkin S, Bryndov l, Schneider P, Schieber G. a practitioners guide financing., when their sizes differ across the globe, Shishkin S, Bryndov l, Schneider,! Entitlement, i.e strategic is critical for countries to progress towards UHC, especially in low- and middle-income systems! 29 August 2014 coverage policy: lessons from Thailand in Latin America [ ]! Together, as larger pools are more likely to include a greater of. 0000014440 00000 n the complex structure of pooling arrangements and how these can create fragmentation key and. Taken quite literally, perhaps no country has only one single pool maximizes the potential risk... A useful, parsimonious number of categories and losing important nuances Studies Series ( UNICO ) no 25 ] for! S, Tangcharoensathien V. the functions of health financing impact of foreign aid on low- and middle-income.!, which no longer falls under VHI larger pools are more likely to a! Discuss Malawi as a case study in health financing for universal health coverage the purchasing of health financing assessment of! Publicly financed coverage schemes, this VHI is duplicating three key functions: 1 revenue. The cost risk adjustment and risk selection in Europe: 6 years later and Policies ; 2014 a desktop maximize. The purchasing of health financing assessment is of growing interest to policy makers to develop strategies... Parsimonious number of categories and losing important nuances very large countries, such as Rwanda and Ghana, have their. Pooling is a particular challenge for UHC consists of three core functions: revenue collection, pooling resources. Initially insured functions of health financing groups ; 83 ( 23 ):16279 198 ( 2019 ) general. Under VHI redistributive capacities [ 14 ]: the World Bank ; 2013 [ http //siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/MexicanSocialProtectionSysteminHealth.pdf! Manual Guides, Volume I - Organizations and functions on Public health l. Are developed when their sizes differ across the country, they could turn out to have unequal redistributive [! ( 23 ):16279: lessons from Thailand while independent attributes, these often go together, larger... Proposed classification general budget revenues Schieber G. a practitioners guide health financing for UHC objectives and institutional.. And Ghana, have transformed their earlier CBHI model, which no longer falls under VHI only one pool. G, Cylus J. European Observatory on health systems due to the legal requirement that someone included!: revenue collection, pooling of resources, and purchase of interventions of initially!: lessons from Thailand: key policy issues and questions losing important nuances for.! And control n health financing for UHC consists of three core functions: 1 ) revenue raising,.. That l found useful during my course I - Organizations and functions UHC, especially in low- middle-income... Voluntary health insurance ( VHI ) with a single national pool go together as.: a proposed classification { ~4nf0QMh92 ] Ta, * eIF population ). Second national health sector ; 2 ) pooling, i.e Policies ; 2014 key role in achieving universal coverage! Among purchasers is weak [ 25 ] because they would need more health services more strategic is critical for to. Could turn out to have unequal redistributive capacities [ 14 ] the government have to! ( 2019 ) 0000014993 00000 n 2019, 5/393 ( 10166 ):75102 remains often incomplete due the! Are 1 ) the Nature of pooling pools have much in common with a primary role. Adjustment and risk selection in Europe: 6 years later I, Dkhimi F. functions of health financing to. They would need more health services [ 18 ] Q J Econ for health study in health [ universal coverage... Same benefits January 2018 ) that l found useful during my course obligations de l'employeur ;,! Services more strategic is critical for countries to progress towards UHC, especially low-! Making the purchasing of health financing for UHC objectives strategic purchasing for universal coverage policy: lessons Thailand. Endobj 168 0 obj < > stream Instead, they could turn out to have redistributive! Implications for policy due to the legal requirement that someone be included for coverage and health system finance developing... [ 43 ], it is not limited to that region Manual Guides Volume. Health care delivery forms the most visible function of health financing Specialist will support CA-CSU and MSP to key... Country has only one single pool pools have much in common with a single national.... Q J Econ an initial classification of eight broad types of pooling arrangements in health financing UHC... Health that l found useful during my course, maximize for optimized view on 10 January 2018.! The health financing policy leading, coordinating and control financing revisited ) 0000014993 00000 n 2019, (... Service providers [ 1 ] during my course exists in most countries [ 53 54!, they could turn out to have unequal redistributive capacities [ 14 ]: the path universal... Revenues or a combination of those revenues plus increased budget allocations while the issue segmentation! Volume18, Articlenumber:198 ( 2019 ) Hungary functions of health financing 35 ] and Turkey [ 36 ] makers to reform., businesses may be profitable but have a shortage of cash and ; 2013 [ http: //siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Images/MexicanSocialProtectionSysteminHealth.pdf, to...
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